Associations between depressive symptom clusters and care utilization and costs among community-dwelling older adults.

OBJECTIVES: Whether and how symptom clusters are associated with care utilization remains understudied. This study aims to investigate the economic impact of symptom clusters. METHODS: We conducted cross-sectional analyses of data collected from 3255 older adults aged 60 years and over in Hong Kong using the Patient Health Questionnaire-9 and the Client Service Receipt Inventory to measure depressive symptoms and service utilization to calculate 1-year care expenditure. Based on Research Domain Criteria framework, we categorized depressive symptoms into four clusters: Negative Valance Systems and Externalizing (NVSE; anhedonia and depression), Negative Valance Systems and Internalizing (guilt and self-harm), Arousal and Regulatory Systems (sleep, fatigue, and appetite), and Cognitive and Sensorimotor Systems (CSS; concentration and psychomotor). Two-part models were used with four symptom clusters to estimate economic impacts on care utilization. RESULTS: Core affective symptoms had the largest economic impact on non-psychiatric care expenditure; a one-point increase in NVSE was associated with USD$ 571 additional non-psychiatric care expenditure. The economic impacts of CSS on non-psychiatric care expenditure was attenuated when the severity level of NVSE was higher. CONCLUSIONS: Our findings highlight the importance of understanding economic impacts on care utilization based on symptom profiles with a particular emphasis on symptom combinations. Policymakers should optimize care allocation based on older adults' depressive symptom profiles rather than simply considering their depression sum-score or the severity defined by cut-off points.

Virtual individual cognitive stimulation therapy in Hong Kong: A mixed methods feasibility study.

OBJECTIVES: We aimed to translate and culturally adapt Virtual Individual Cognitive Stimulation Therapy (V-iCST) for the Hong Kong (HK) Chinese population, and to evaluate its feasibility and acceptability. METHODS: A mixed methods case series (N=8) was used to assess the feasibility of V-iCST and changes in cognition, quality of life (QoL), mood, and communication pre and post-test. Data were analyzed with the reliable change index. Thematic analysis of post-therapy interviews and content analysis of session rating forms were used to evaluate the acceptability. RESULTS: V-iCST was feasible with low attrition (0%) and high attendance (100%). Participants had reliable improvements in all outcomes. Six had improved and stable cognition; four had clinically significant changes in depression. There were no reliable changes in QoL. Qualitative analyses indicated V-iCST as acceptable but required assistance. CONCLUSIONS: V-iCST can be adapted for HK Chinese with dementia and potentially improve cognition, QoL, mood, and communication.

Small-World Networks and Their Relationship With Hippocampal Glutamine/Glutamate Concentration in Healthy Adults With Varying Genetic Risk for Alzheimer's Disease.

BACKGROUND: Apolipoprotein E ɛ4 allele (ApoE4) is the most common gene polymorphism related to Alzheimer's disease (AD). Impaired synaptic dysfunction occurs in ApoE4 carriers before any clinical symptoms. It remains unknown whether ApoE4 status affects the hippocampal neuromodulation, which further influences brain network topology. PURPOSE: To study the relationship of regional and global network properties by using graph theory analysis and glutamatergic (Glx) neuromodulation in the ApoE isoforms. STUDY TYPE: Prospective. SUBJECTS: Eighty-four cognitively normal adults (26 ApoE4 and 58 non-ApoE4 carriers). FIELD STRENGTH/SEQUENCE: Gradient-echo echo-planar and point resolved spectroscopy sequence at 3 T. ASSESSMENT: Glx concentration in bilateral hippocampi were processed with jMRUI (4.0), and graph theory metrics (global: γ, λ, small-worldness in whole brain; regional: nodal clustering coefficient (Ci ) and nodal characteristic path length (Li )) in top 20% highly connected hubs of subgroups (low-risk: non-ApoE4; high-risk: APOE4) were calculated and compared. STATISTICAL TESTS: Two-sample t test was used to compare metrics between subgroups. Correlations between regional properties and Glx by Pearson's partial correlation with false discovery rate correction. RESULTS: Significant differences (P < 0.05) in Ci between subgroups were found in hubs of left inferior frontal, bilateral inferior temporal, and bilateral precentral gyri, right parahippocampus, and bilateral precuneus. In addition, there was a significant correlation between Glx in the left hippocampus and Ci in inferior frontal gyrus (r = -0.537, P = 0.024), right inferior temporal (r = -0.478, P = 0.043), right parahippocampus (r = -0.629, P = 0.016), left precentral (r = -0.581, P = 0.022), right precentral (r = -0.651, P = 0.003), left precuneus (r = -0.545, P = 0.024), and right precuneus (r = -0.567, P = 0.022); and Li in left precuneus (r = 0.575, P = 0.032) and right precuneus (r = 0.586, P = 0.032) in the high-risk group, but not in the low-risk group. DATA CONCLUSION: Our results suggested that healthy ApoE4 carriers exhibit poorer local interconnectivity. Moreover, the close relationship between glutamate and small-world network properties in ApoE4 carriers might reflect a compensatory response to the impaired network efficiency. EVIDENCE LEVEL: 2 TECHNICAL EFFICACY: Stage 3.

Systematic review of the current psychosocial interventions for people with moderate to severe dementia.

OBJECTIVE: Dementia, a global epidemic, currently affects 50 million individuals worldwide. There are currently limited effective treatments for moderate to severe dementia, and most treatments focus on reducing symptoms rather than improving positive factors. It is unclear if improvements are not possible due to disease severity. This review examines the efficacy of the current psychosocial interventions for people with moderate to severe dementia, focusing on improving cognition and quality of life (QoL) to evaluate what treatments are working and whether improvements are possible. METHODS: A systematic search was conducted using six key databases to identify psychosocial interventions for people with moderate to severe dementia, measuring cognition or QoL in randomized controlled trials (RCTs), published between 2000 and 2020. RESULTS: The search identified 4193 studies, and 74 articles were assessed for full-text review. Fourteen RCTs were included and appraised with the Physiotherapy Evidence Database Scale. The included RCTs were moderate in quality. CONCLUSIONS: Aromatherapy and reminiscence therapy showed the strongest evidence in improving QoL. There was some evidence that aerobic exercise enhanced cognition, and a multicomponent study improved QoL. However, a quality assessment, using pre-specified criteria, indicated many methodological weaknesses. While we found improvements in cognition and QoL for moderate to severe dementia, results must be interpreted with caution. Future interventions with rigorous study designs are a pressing need and required before we can recommend specific interventions.

Prevalence of depression, anxiety, and apathy symptoms across dementia stages: A systematic review and meta-analysis.

OBJECTIVE: The present study aimed to resolve inconsistency in reported prevalence of affective symptoms by dementia stage. METHODS/DESIGN: We conducted a meta-analysis of studies with data on dementia stage and prevalence of depression, anxiety, or apathy assessed using validated tools. We performed random-effects meta-analysis and subgroup analysis on symptom prevalence by dementia stage, according to CDR. RESULTS: The meta-analysis included 5897 people with dementia from 20 studies. Prevalence rates of depression in mild, moderate, and severe dementia were 38% (95% CI 32%-45%), 41% (95% CI 33%-49%), and 37% (95% CI 17%-56%) respectively. The corresponding prevalence for anxiety was 38% (95% CI 31%-45%), 41% (95% CI 31%-52%), and 37% (95% CI -8%-82%); and 54% (95% CI 45%-62%), 59% (95% CI 44%-73%), and 43% (95% CI 10%-75%) for apathy. The prevalence of depression, anxiety, and apathy did not differ with regard to dementia stage and type. The prevalence of depression in Alzheimer's disease (AD) was significantly lower when it was assessed using diagnostic criteria compared to screening tools. The prevalence of depression in AD was lowest in America, while anxiety in vascular dementia was higher in Europe than Asia. CONCLUSIONS: Depression, anxiety, and apathy symptoms are highly prevalent across dementia stages. There is no evidence of any changes in prevalence of affective symptom as the illness progresses. Evaluation methods and cultural difference may explain some of the variance, suggesting further investigation of factors that may influence the report of symptoms, such as carer psychosocial characteristics, and more cross-cultural studies are needed.

Access and Unmet Needs of Orphan Drugs in 194 Countries and 6 Areas: A Global Policy Review With Content Analysis.

OBJECTIVES: Three hundred million people living with rare diseases worldwide are disproportionately deprived of in-time diagnosis and treatment compared with other patients. This review provides an overview of global policies that optimize development, licensing, pricing, and reimbursement of orphan drugs. METHODS: Pharmaceutical legislation and policies related to access and regulation of orphan drugs were examined from 194 World Health Organization member countries and 6 areas. Orphan drug policies (ODPs) were identified through internet search, emails to national pharmacovigilance centers, and systematic academic literature search. Texts from selected publications were extracted for content analysis. RESULTS: One hundred seventy-two drug regulation documents and 77 academic publications from 162 countries/areas were included. Ninety-two of 200 countries/areas (46.0%) had documentation on ODPs. Thirty-four subthemes from content analysis were categorized into 6 policy themes, namely, orphan drug designation, marketing authorization, safety and efficacy requirements, price regulation, incentives that encourage market availability, and incentives that encourage research and development. Countries/areas with ODPs were statistically wealthier (gross national income per capita = $10 875 vs $3950, P < .001). Country/area income was also positively correlated with the scope of the respective ODP (correlation coefficient = 0.57, P < .001). CONCLUSIONS: Globally, the number of countries with an ODP has grown rapidly since 2013. Nevertheless, disparities in geographical distribution and income levels affect the establishment of ODPs. Furthermore, identified policy gaps in price regulation, incentives that encourage market availability, and incentives that encourage research and development should be addressed to improve access to available and affordable orphan drugs.

Cultural adaptation of cognitive stimulation therapy (CST) for Chinese people with dementia: multicentre pilot study.

OBJECTIVE: Ageing of the Chinese population will drive a continued surge in dementia prevalence. Empirically tested non-pharmacological interventions developed in western cultures may be implemented in Chinese. Cognitive Stimulation Therapy (CST) that originated in the UK has proven benefits on cognition and quality of life in people with dementia. We investigated the feasibility and cultural appropriateness of CST in Hong Kong Chinese (CST-HK). METHODS: Mixed methods research was conducted following the formative method for adapting psychotherapy. A culturally adapted CST-HK, developed involving multidisciplinary stakeholders, was tested in a pilot multicentre study in people with mild dementia (n = 30) receiving community or residential care. Changes in cognition and quality of life were measured. Opinions from family caregivers and group facilitators (n = 25) were collected through focus groups and in-depth interviews for understanding the appropriateness of CST-HK. Feasibility was explored. RESULTS: After receiving CST-HK, 54% of participants achieved outcome of no cognitive deterioration, and 23% showed clinically meaningful improvement. Family caregivers and group facilitators expressed good acceptance of CST, with a low attrition (13%) and high attendance rate of CST-HK sessions (92%). Key cultural issues identified are (i) less active opinion sharing in group discussions due to conservatism/cautiousness and (ii) preference of practical activities with reward/recognition over pure discussion due to pragmatism. CONCLUSIONS: The CST-HK is feasible and culturally appropriate in Hong Kong Chinese. Further amendments can be made to ensure language use and enjoyment, with potential implications on effectiveness. We have provided a systematically developed, culturally adapted protocol for larger-scale implementation and research in Chinese populations. Copyright © 2017 John Wiley & Sons, Ltd.

Increased distractibility to own name in psychotic patients with ideas and delusions of reference.

INTRODUCTION: This study examined the relationship between ideas and delusions of reference (I/DOR) and attentional shift to a self-referential stimulus (subject's own name, SON). METHODS: Psychotic patients with I/DOR (n = 20) and without I/DOR (n = 17) matched for age and education were tested for attentional shift to SON embedded in a background voice clip presented binaurally when engaging in an attention-demanding task (computerised Stroop task). Reaction time and accuracy in Stroop tasks with and without embedded SON were measured. I/DOR severity, other positive symptoms, negative symptoms and cognitive performance were assessed. RESULTS: There was significant interaction between conditions (Stroop tasks with and without SON) and groups (patients with and without I/DOR) on reaction time (F(1,32) = 4.22, p = .05). Simple main effects showed a significant mean difference in reaction time between conditions in patients with I/DOR (107.7 milliseconds, p = .001) but not in those without (5.8 milliseconds, p = .86). Within-subject difference in reaction time correlated with I/DOR severity scores (r = .33-.52, range; p < .05) and remained significant after controlling for other clinical and cognitive variables. CONCLUSIONS: The significant interaction and simple main effect suggest that I/DOR are associated with a heightened attentional shift to SON. The SON paradigm can potentially be developed into a neurocognitive parameter of I/DOR. However, the lack of non-self stimuli in the SON paradigm limits the interpretation on whether I/DOR are associated with general or specific distractibility related to self-referential information and further studies are warranted.

Neighborhood support network, perceived proximity to community facilities and depressive symptoms among low socioeconomic status Chinese elders.

OBJECTIVES: Depressive symptoms are common in older people; most previous research on elderly depression focused on individual-level characteristics or neighborhood socioeconomic status. Modifiable neighborhood characteristics of older people dwelling in low-income communities are under-studied. This study aims to identify potentially modifiable social and physical neighborhood characteristics that influence depressive symptoms independent of individual-level characteristics among older Chinese. METHOD: Data came from a cross-sectional survey conducted in four low-income public rental housing estates in Hong Kong in 2012. We interviewed a total of 400 elderly residents. The structured questionnaire covered demographics, activities of daily living, recent fall history, neighborhood support networks, and perceived proximity by walk to community facilities. Multiple regression was used to test whether inclusion of neighborhood factors in addition to individual characteristics increases model fit in explaining depressive symptoms in elders with low socioeconomic status. RESULTS: At individual level, activities of daily living and income significantly predicted depressive symptoms. Receiving support from friends or neighbors is associated with fewer depressive symptoms. However, participants who received organizational support had a 1.17 points of increase on the 15-item Geriatric Depression Scale (GDS-15). At-ease walkable proximity to medical facilities was positively associated with a better GDS score. CONCLUSION: Neighborhood support networks and perceived proximity by walk to community facilities contribute significantly to depressive symptoms among low-income elders. Programs and policies that facilitate neighborhood support and commuting or promote facility accessibility may help ameliorate depressive symptoms common among low-income elders.

Identifying dementia from cognitive footprints in hospital records among Chinese older adults: a machine-learning study.

Background: By combining theory-driven and data-driven methods, this study aimed to develop dementia predictive algorithms among Chinese older adults guided by the cognitive footprint theory. Methods: Electronic medical records from the Clinical Data Analysis and Reporting System in Hong Kong were employed. We included patients with dementia diagnosed at 65+ between 2010 and 2018, and 1:1 matched dementia-free controls. We identified 51 features, comprising exposures to established modifiable factors and other factors before and after 65 years old. The performances of four machine learning models, including LASSO, Multilayer perceptron (MLP), XGBoost, and LightGBM, were compared with logistic regression models, for all patients and subgroups by age. Findings: A total of 159,920 individuals (40.5% male; mean age [SD]: 83.97 [7.38]) were included. Compared with the model included established modifiable factors only (area under the curve [AUC] 0.689, 95% CI [0.684, 0.694]), the predictive accuracy substantially improved for models with all factors (0.774, [0.770, 0.778]). Machine learning and logistic regression models performed similarly, with AUC ranged between 0.773 (0.768, 0.777) for LASSO and 0.780 (0.776, 0.784) for MLP. Antipsychotics, education, antidepressants, head injury, and stroke were identified as the most important predictors in the total sample. Age-specific models identified different important features, with cardiovascular and infectious diseases becoming prominent in older ages. Interpretation: The models showed satisfactory performances in identifying dementia. These algorithms can be used in clinical practice to assist decision making and allow timely interventions cost-effectively. Funding: The Research Grants Council of Hong Kong under the Early Career Scheme 27110519.

A 3-year retrospective cohort study of predictors of relapse in first-episode psychosis in Hong Kong.

OBJECTIVE: Relapses in psychosis are costly and may have irreversible consequences. Relapse prevention is thus critical in the treatment of schizophrenia. Apart from medication discontinuation, a consistent relapse predictor has not been identified due to limitations in previous studies. We aim to investigate relapse predictors in a large cohort of patients with first-episode psychosis. METHOD: This is a retrospective cohort study designed to evaluate relapses in first-episode psychosis patients in 3 years. A total of 1400 patients' case records were retrieved from a hospital database. Potential relapse predictors including demographic variables, baseline clinical measures, medication adherence, and residual positive symptoms upon clinical stabilization were collected. RESULTS: The cumulative relapse rates were 19.3% by year 1, 38.4% by year 2, and 48.1% by year 3. Multivariate Cox-proportional hazards regression analysis revealed that medication non-adherence, smoking, schizophrenia diagnosis, younger age, and shorter baseline hospitalization were associated with an increased risk of relapse in 3 years. CONCLUSIONS: Nearly half of patients relapsed after 3 years following their first-episode psychosis. Smoking as a predictor of relapse is an intriguing new finding supportive of a link between nicotinic receptors and the dopamine system. Their relationship deserves further investigations with potential clinical implications for relapse prevention.

Predictors of help-seeking duration in adult-onset psychosis in Hong Kong.

PURPOSE: Delay in receiving treatment in psychosis may lead to adverse consequences. We examined the predictors for help-seeking duration in adult-onset psychosis Chinese patients in Hong Kong. We hypothesized that factors which are more related to the illness manifestation would be predictive of waiting time before any help-seeking initiation, and factors which are more related to one's knowledge about mental health services would be predictive of help-seeking duration. METHODS: First-episode patients with psychosis were recruited from the Jockey Club Early Psychosis project. They were asked to report retrospectively all help-seeking behaviors involved since their first occurrence of psychotic symptoms until receipt of effective psychiatric treatment. Baseline characteristics, pre-morbid functioning and traits, and mode of illness onset were assessed. RESULTS: Help-seeking pattern was analyzed in 360 patients who had subsequently reached the psychiatric services. They had an average of 2.5 help-seeking contacts. Nearly half of the first help-seeking process was initiated by family members. Only 1 % approached priests or traditional healers as the first step in help-seeking. Whereas a gradual mode of onset was significantly associated with longer waiting time to first help-seeking initiation, more premorbid schizoid and schizotypal traits and a migrant status were related to longer help-seeking duration. CONCLUSIONS: Current findings suggested that family members were the key decision makers in initiating help-seeking. Longer help-seeking duration in migrants has significant implications to both local and global mental health policy.

Differential Associations Between Depressive Symptom-Domains With Anxiety, Loneliness, and Cognition in a Sample of Community Older Chinese Adults: A Multiple Indicators Multiple Causes Approach.

Background and Objectives: Depressive symptoms are common in older adults, and often co-occur with other mental health problems. However, knowledge about depressive symptom-domains and their associations with other conditions is limited. This study examined depressive symptom-domains and associations with anxiety, cognition, and loneliness. Research Design and Methods: A sample of 3,795 participants aged 60 years and older were recruited from the community in Hong Kong. They were assessed for depressive symptoms (Patient Health Questionnaire-9 [PHQ-9]), anxiety (Generalized Anxiety Disorder 7-item), loneliness (UCLA 3-item), and cognition (Montreal Cognitive Assessment 5-Minute Protocol). Summary descriptive statistics were calculated, followed by confirmatory factor analysis of PHQ-9. Multiple Indicators Multiple Causes analysis was used to examine the associations between mental health conditions in the general sample and subgroups based on depressive symptom severity. Results: A 4-factor model based on the Research Domain Criteria showed the best model fit of PHQ-9 (χ2/df = 10.63, Root-Mean-Square Error of Approximation = 0.05, Comparative Fit Index = 0.96, Tucker-Lewis Index = 0.93). After adjusting for demographics, 4 depressive symptom-domains were differentially associated with anxiety, loneliness, and cognition across different depression severity groups. The Negative Valance Systems and Internalizing domain (NVS-I; guilt and self-harm) were consistently associated with anxiety (ß = 0.45, 0.44) and loneliness (ß = 0.11, 0.27) regardless of depression severity (at risk/mild vs moderate and more severe, respectively, all p < .001). Discussion and Implications: The consistent associations between the NVS-I domain of depression with anxiety and loneliness warrant attention. Simultaneous considerations of depressive symptom-domains and symptom severity are needed for designing more personalized care. Clinical Trials Registration Number: NCT03593889.

Spoken discourse in episodic autobiographical and verbal short-term memory in Chinese people with dementia: the roles of global coherence and informativeness.

Introduction: Memory and discourse production are closely related in healthy populations. A few studies in people with amnestic mild cognitive impairment and people with dementia (PWD) suggested similar links, although empirical evidence is insufficient to inform emerging intervention design and natural language processing research. Fine-grained discourse assessment is needed to understand their complex relationship in PWD. Methods: Spoken samples from 104 PWD were elicited using personal narrative and sequential picture description and assessed using Main Concept Analysis and other content-based analytic methods. Discourse and memory performance data were analyzed in bivariate correlation and linear multiple regression models to determine the relationship between discourse production and episodic autobiographical memory and verbal short-term memory (vSTM). Results: Global coherence was a significant predictor of episodic autobiographical memory, explaining over half of the variance. Both episodic autobiographical memory and vSTM were positively correlated with global coherence and informativeness, and negatively with empty speech indices. Discussion: Coherence in personal narrative may be supported by episodic autobiographical memory and vice versa, suggesting potential mechanism of interventions targeting personhood through conversation. Indices of global coherence, informativeness, and empty speech can be used as markers of memory functions in PWD.

Patient Health Questionnaire-9 Item Pairing Predictiveness for Prescreening Depressive Symptomatology: Machine Learning Analysis.

BACKGROUND: Anhedonia and depressed mood are considered the cardinal symptoms of major depressive disorder. These are the first 2 items of the Patient Health Questionnaire (PHQ)-9 and comprise the ultrabrief PHQ-2 used for prescreening depressive symptomatology. The prescreening performance of alternative PHQ-9 item pairings is rarely compared with that of the PHQ-2. OBJECTIVE: This study aims to use machine learning (ML) with the PHQ-9 items to identify and validate the most predictive 2-item depressive symptomatology ultrabrief questionnaire and to test the generalizability of the best pairings found on the primary data set, with 6 external data sets from different populations to validate their use as prescreening instruments. METHODS: All 36 possible PHQ-9 item pairings (each yielding scores of 0-6) were investigated using ML-based methods with logistic regression models. Their performances were evaluated based on the classification of depressive symptomatology, defined as PHQ-9 scores ≥10. This gave each pairing an equal opportunity and avoided any bias in item pairing selection. RESULTS: The ML-based PHQ-9 items 2 and 4 (phq2&4), the depressed mood and low-energy item pairing, and PHQ-9 items 2 and 8 (phq2&8), the depressed mood and psychomotor retardation or agitation item pairing, were found to be the best on the primary data set training split. They generalized well on the primary data set test split with area under the curves (AUCs) of 0.954 and 0.946, respectively, compared with an AUC of 0.942 for the PHQ-2. The phq2&4 had a higher AUC than the PHQ-2 on all 6 external data sets, and the phq2&8 had a higher AUC than the PHQ-2 on 3 data sets. The phq2&4 had the highest Youden index (an unweighted average of sensitivity and specificity) on 2 external data sets, and the phq2&8 had the highest Youden index on another 2. The PHQ-2≥2 cutoff also had the highest Youden index on 2 external data sets, joint highest with the phq2&4 on 1, but its performance fluctuated the most. The PHQ-2≥3 cutoff had the highest Youden index on 1 external data set. The sensitivity and specificity achieved by the phq2&4 and phq2&8 were more evenly balanced than the PHQ-2≥2 and ≥3 cutoffs. CONCLUSIONS: The PHQ-2 did not prove to be a more effective prescreening instrument when compared with other PHQ-9 item pairings. Evaluating all item pairings showed that, compared with alternative partner items, the anhedonia item underperformed alongside the depressed mood item. This suggests that the inclusion of anhedonia as a core symptom of depression and its presence in ultrabrief questionnaires may be incompatible with the empirical evidence. The use of the PHQ-2 to prescreen for depressive symptomatology could result in a greater number of misclassifications than alternative item pairings.

Applying motivational framework in medical education: a self-determination theory perspectives.

BACKGROUND: The application of self-determination theory in explaining student achievement has been well-established in various contexts. However, its application to medical education, particularly in interprofessional education (IPE) remains underexplored. Understanding how students' motivation plays a role in students' engagement and achievement is essential to optimize efforts to improve learning and instruction. OBJECTIVE: This two-stage study aims to contextualize the SDT framework to IPE through the adaptation of the Basic Psychological Need Satisfaction to IPE (Study 1) and to demonstrate how SDT can be applied in IPE by examining a model of SDT constructs (Study 2) in predicting outcomes (behavioral engagement, team effectiveness, collective dedication, goal achievement). DESIGN: In Study 1 (n=996), we adapted and validated BPNS-IPE using confirmatory factor analysis and multiple linear regression using data from 996 IPE students (Chinese Medicine, Medicine, Nursing, and Pharmacy). In Study 2 (n=271), we implemented an IPE program where we integrated SDT approaches and examined the relationship of SDT constructs with IPE outcomes using multiple linear regression. RESULTS: Our data supported the three-factor structure (autonomy, competence, and relatedness) of BPNS-IPE, meeting the required model fit. Autonomy predicted team effectiveness (F=51.290, p<.05, R2=.580); competence predicted behavioral engagement (F=55.181, p<.05, R2=.598); while relatedness predicted significantly four IPE outcomes: behavioral engagement (F=55.181, p<.01, R2=.598), team effectiveness (F=51.290, p<.01, R2=.580), collective dedication (F=49.858, p<.01, R2=.573), goal achievement (F=68.713, p<.01, R2=.649). CONCLUSIONS: The SDT motivational framework can be adapted and applied in the IPE context to understand and enhance student motivation in medical education. Potential studies with the use of the scale are provided to guide researchers.

Longitudinal measurement properties of the Montreal Cognitive Assessment.

INTRODUCTION: The Montreal Cognitive Assessment (MoCA) has started to be used in longitudinal investigations to measure cognition trends but its measurement properties over time are largely unknown. This study aimed to examine the longitudinal measurement invariance of individual MoCA items. METHOD: We used four waves of data collected between 2014 and 2017 from a cohort study on health and well-being of older adults from twelve public housing estates in Hong Kong. We identified people aged 65 years or older at baseline who answered the MoCA items across all time points and had a valid indicator of educational level. A total of 1028 participants were included. We applied confirmatory factor analysis of ordinal variables to examine measurement invariance of the Chinese (Cantonese) MoCA (version 7.0) items across four time points, stratified by educational level, where invariant items were identified by sequential model comparisons. RESULTS: Four items exhibited a lack of measurement invariance across the four time points in both education groups (Clock Hand, abstraction, Delayed Recall, and Orientation). The items Cube and Sentence Repetition lacked longitudinal measurement invariance only in the "some education" group and the items Clock Shape and Clock Number only in the "no education" group. However, accounting for the lack of measurement invariance did not substantially affect classification properties for major neurocognitive disorder and mild cognitive impairment. CONCLUSIONS: Our findings support using MoCA to assess changes in cognition over time in the study population while calling for future research in other populations.

Are we on the same page? Multiple stakeholders and service users priorities for dementia care and policy: A Delphi study.

BACKGROUND: It's crucial to develop a national policy for dementia due to the growing number of persons living with the condition and the attendant impact on individuals, families, and society at large. However, there has been limited exploration of the views on long-term goals for dementia of different stakeholders involved in different aspects of service use, planning or delivery. OBJECTIVE: This study aims to examine and compare the perceived priorities of service users (i.e., people living with dementia and their family caregivers) and other multiple stakeholders for dementia care and policy. DESIGN: Two independent Delphi studies were conducted in Hong Kong. SETTING(S) AND PARTICIPANTS: In Delphi study 1, 75 stakeholders were recruited from public and private nursing, medical and social care providers, philanthropic organizations, policy-makers and government sectors. In Delphi study 2, 45 people living with dementia and 55 family caregivers were recruited from community care settings. METHODS: The Delphi study 1 was conducted using online surveys, while the Delphi study 2 was conducted using phone interviews. Each Delphi study comprised a qualitative study for exploring the range of views of the two panels and a quantitative validation for generating consensus. We systematically compared the two panels' identified priorities in terms of contents and consensus levels. RESULTS: Multiple stakeholders identified 32 consensus-based statements and service users identified 25 statements, most of which achieved moderate to high level of consensus. Through content analysis, statements from the two panels were converged into six common themes: (1) early prevention, detection and referral systems for dementia, (2) care and intervention services, (3) health and social care workforce capacity building within and across service sectors, (4) supportive services for family caregivers, (5) development of longer-term dementia service planning and a policy framework, and (6) promotion of a dementia-friendly community. Despite the similarity of the themes expressed by the two panels, critical comparison of their priorities identified the dementia service and policy gaps in providing integrated and informed healthcare, a mechanism for sensitive care allocation, enabling seamless social inclusion, and proactive health orientation of dementia caregivers. CONCLUSIONS: Discrepancies between two panels reflect the distinctive value of service user engagement in the policy-making process. Our findings have implications for developing a multi-disciplinary integrated action plan for the local health response across the primary and secondary care settings to dementia and expanding the practice scope of person-centered dementia care in a collaborative way. TWEETABLE ABSTRACT: The voices of user, caregivers and service stakeholders excel the person-centered care and policy context for integrated dementia care.

Delivering Cognitive Stimulation Therapy (CST) Virtually: Developing and Field-Testing a New Framework.

PURPOSE: This feasibility and pilot study aimed to develop and field-test a 14-session virtual Cognitive Stimulation Therapy (vCST) programme for people living with dementia, developed as a result of services moving online during the COVID-19 pandemic. METHODS: The vCST protocol was developed using the existing group CST manual, through stakeholder consultation with people living with dementia, caregivers, CST group facilitators and dementia service managers. This protocol was then field-tested with 10 groups of people living with dementia in the Brazil, China (Hong Kong), India, Ireland and the UK, and feedback on the protocol was gathered from 14 facilitators. RESULTS: Field testing in five countries indicated acceptability to group facilitators and participants. Feedback from these groups was used to refine the developed protocol. The final vCST protocol is proposed, including session materials for delivery of CST over videoconferencing and a framework for offering CST virtually in global settings. CONCLUSION: vCST is a feasible online intervention for many people living with dementia. We recommend that it is offered to those unable to access traditional in-person CST for health reasons, lack of transport or COVID-19 restrictions. Further research is needed to explore if participant outcomes are comparable to in-person CST groups.